Tag Archives: Optimal Care in Childbirth

I’m a pediatrician. My interest in childbirth, from the time I finished my obstetrics rotation in medical school until I began writing my book, Birth Day, in the mid-2000s, was focused on what I needed to know in the course of preparing for the arrival of a sick newborn. What’s the gestational age? Any maternal illnesses? How’s the fetal heart tracing? Then I’d set out my tools and watch and wait until my new patient emerged from his mother.

I confess I did not give much thought to what was being done to the mother in the course of her giving birth, whether it was an induction, an episiotomy, or as happened more and more frequently over the years, a cesarean. Babies were my business; I was only peripherally aware of any obstetrical controversies smoldering behind the scenes.

My research for Birth Day was a crash course in the science and politics—especially the politics—of childbirth. I was introduced to the deep divide between what I’ve come to think of as the right and left wings of American maternity care.

At the extremes I saw a clash of incompatible cultures: the “all technology, all the time” (right-wing) camp–which viewed childbirth as a potentially lethal affair and managed laboring women accordingly–versus the solo, unassisted (lefty) birthers whose only desire was to be ignored by doctors and their interventions as nature took its wise, benign course. From many of the the emails I received from Birth Day readers, there really didn’t seem to be much in between.

The research literature of childbirth is the battlefield on which these “baby wars” have long been fought, a landscape littered with studies–some excellent, some awful–that support just about any conclusion an observer might want to make. Take a hot-wire topic like cesarean section. Depending on the biases and prejudices of the author, the same operation can be an unqualified boon to mankind or the devil’s own handiwork. Separating the research wheat from the chaff, the solid evidence from the cherry-picked, can be a daunting task.

Professional life has not been easy for Goer and Romano. In the introductory chapters of Optimal Care they describe the conflict between the birth-as-pathology-oriented medical management (MM) model of care so prevalent in the U.S. (the obstetric right wing, in my mental construct), and the low-intervention physiologic care (PC) model that emphasizes birth as a normal event and a major life milestone marking

Henci Goer

the transition to parenthood. Despite the authors’ declaration that “every group that has ever set out to design a healthy maternity care system has articulated the principles and practices” of the PC model, change in the American way of birth has been slow and incremental.

“The [PC model] wheel has been reinvented repeatedly, yet somehow we cannot get it rolling. The obvious question then becomes, Why not?”

Goer and Romano then line up the suspects, usual and not, for the maddeningly unmovable status quo. There’s money, of course—the perverse economic incentives that support hospital maternity wards and the expensive technologies that come with them—and the inertia of entrenched habits and practices. Too, there is the belief held by many women, often reinforced by their maternity care providers, that their bodies are not competent for the task of giving birth.

Interestingly, Goer and Romano also cite the rise of “evidence-based decision-making” in medicine (or, as the late Canadian obstetrician Phil Hall described it, “decision-based evidence making”) as a self-reinforcer of conventional obstetric care. When an evidence-gathering framework designed to evaluate the treatment of illness is instead applied to a normal physiologic process, the result is an increasingly narrow definition of “normal” and a much broader one of “pathology.” Of such thinking, the authors conclude, comes the likes of early labor induction, routine episiotomies, and skyrocketing cesarean rates—and the incredibly difficult task of trying to change an obstetric culture so committed to the MM model that the benefits of all births being cesareans is actually considered a legitimate topic of discussion.

“By now you may be thinking that the situation is hopeless; resistance is futile.”

Well, yes, that thought does cross a reader’s mind. The research deck does seem to be stacked in favor of medical management. So, given decades of crying in the childbirth wilderness, what keeps Goer and Romano going? Why haven’t they surrendered to the inexorable march of techno-birthing? How have they not gone completely nuts?

“It is not [hopeless],” Goer and Romano insist, “but those wanting to reform maternity care need a solid foundation in what the obstetric evidence does, does not, or only seems to support, as well as an

Amy Romano

understanding of the impediments to change…”

In other words, you have to fight “science” with science, and that is what Goer and Romano do so well in this fine book.

Optimal Care is a hefty volume–nearly 600 pages—and not every reader will want to plow through it from start to finish. There’s really no need to, though—the book’s structure invites focused reading. Each of its eight sections is divided into chapters that hone in on specific aspects of a more general topic. A reader interested in the subject of episiotomies, say, need read only the twenty pages of Chapter 15 to learn why episiotomies are rarely necessary, and why, despite that evidence, they are still commonly performed. Meanwhile, those who wish to read about a more complicated topic like cesarean section will find an in-depth discussion of the science and politics of that surgery spread over the three chapters of Section II, “The Cesarean Epidemic.”

I found two features of Optimal Care in Childbirth particularly helpful for busy clinicians. At the end of each chapter are concise, bulleted “Strategies for Optimal Care” designed to promote physiologic birth in a variety of settings. Following that are “Mini-Reviews”—summaries of topic-related research which include, notably, the authors’ reasons for including and excluding certain studies. Goer and Romano are refreshingly upfront about their PC model biases—literally from page one—an honest and rare thing to see in the highly polarized world of modern maternity care.

Optimal Care in Childbirth is a welcome addition to the ever-expanding library of maternity care books. By using science in the service of physiologic birth, Henci Goer and Amy Romano offer a welcome push-back to the all too common view of uncomplicated childbirth as a disaster just waiting to happen.